Medicare Wellness Visits for FQHCs

Medicare Wellness Visit

Who is eligible for an IPPE or AWV? Medicare covers an AWV for all beneficiaries who are no longer within 12 months after the eligibility date for their first Medicare Part B benefit period, and who have not had either an IPPE or an AWV within the past 12 months. Medicare pays for only one first AWV per beneficiary per lifetime and one subsequent AWV per year thereafter.

Initial Preventative Physical Exam (IPPE): What’s Required? Health Risk Assessment Family, Medical, and Surgical History List of Current Providers Vitals (Including BMI) Cognitive Assessment Depression Screening Advance Care Planning Services (At the discretion of the Beneficiary) Functional Ability Falls Risk ADLs Hearing Impairment Home Safety Screening Schedule for the Next 5-10 years (Recommendations from the USPTF and ACIP) List of Risk Factors Health Advice, Referrals, Health Education, Preventative Counseling

Annual Wellness Visit (AWV) What’s Required? Review and Update Health Risk Assessment Update Family, Medical, and Surgical History Update List of Current Providers Vitals (Including BMI) Cognitive Assessment Depression Screening Advance Care Planning Services (At the discretion of the Beneficiary) Functional Ability Falls Risk ADLs Update the Screening Schedule for the Next 5-10 years (Recommendations from the USPTF and ACIP) Update the list of Risk Factors Health Advice, Referrals, Health Education, Preventative Counseling

Coding for the IPPE and AWV Note: Refer to your billing and coding staff at your health centers for appropriate billing processes. Coding practices may differ based on coding and billing workflows. This information is to provide guidance on codes accepted by CMS only. For more information on FQHC billing, please refer to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf

Billing for the IPPE and AWV

Coding the Advance Care Planning ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a beneficiary to discuss the beneficiary’s wishes and preferences for medical treatment if they are unable to speak or make decisions in the future. You can provide the ACP at the time of the AWV, at the beneficiary’s discretion. Not subject to a deductible and co-pay ONLY when performed during an Annual Wellness Visit or Initial Preventative Physical Exam A diagnosis code must be included when billing

AFTER Patient arrives at PHS BEFORE Patient arrives at PHS SITE: MA (Assessment) Start AWV document Red carpet patient Falls assessment Perform TUG Assessment (If needed) Bring to Room Check and record vitals Depression Screen > 65yo use Geriatric Screen < 65yo use PHQ9 View All Protocols Notify Pharm via IM that pt is ready SITE: CARE TEAM Re-scrub schedule for flips Pre-Visit Planning Huddle SITE: PHARMACY Begin medication reconciliation Document allergies Enter medication refills Click “Verify Medications” Button SITE: CM/MA/RN Acquire Information (CM) ADL/IADL/Risk Factors Establish list of current providers PMH/FH/SH Advance Directives Mini Cog PACE eligibility Counsel (RN) Care plan education Document assessments CPOE Order vaccines If needed (MA) Administer vaccines Give iFOBT SITE: PROVIDER Review assessments Confirm f/up plan Perform BRIEF face-to-face Provider signs off Print Clinic Visit Summary (CVS) Give to pt and walk to next area OR IM MA and MA can give CVS to pt and walk to next area IF NEEDED LAB: Bloodwork if appropriate (5 days) PHARMACY: Pick up meds Visit Complete PHS Annual Wellness Visit Checklist

BEFORE Patient arrives at PHS AFTER Patient arrives at PHS PHS Annual Wellness Visit Work Flow Before AWV Day of AWV Day of AWV BEFORE Patient arrives at PHS SITE: PROVIDER Review assessments Confirm f/up plan Perform BRIEF face-to-face Provider signs off Print Clinic Visit Summary (CVS) Give CVS to patient and walk to next area OR IM MA and MA can give CVS to pt and walk to next area CORP: POP MGMT Identify patients Distribute reports SITE: CARE TEAM Re-scrub schedule for flips Pre-Visit Planning Huddle AFTER Patient arrives at PHS SITE: POP MGMT Pop Mgmt. Calls Admin pop-ups Clinical pop-ups Both w/ end dates All team members schedule: As Add-On or RN Slot Use TTT in provider slot 40 mins later PCC confirms calls Reminds patient to bring pill/med bottles SITE: MA (Assessment) Start AWV document Red carpet patient Falls assessment TUG Assessment if needed Bring to room Check and record vitals Depression Screen > 65yo use Geriatric Screen < 65yo use PHQ9 View All Protocols Notify Pharm via IM IF NEEDED Patient to Lab: Bloodwork if appropriate Remind pt that it takes 5 days for lab results to come back Patient to Pharmacy Pick up medications SITE: PHARMACY Begin medication reconciliation Document allergies Enter medication refills Click “Verify Medications” Button PRE-VISIT PLANNING Care Management (CM) Review weekly schedule Friday before AWV Look for flips Make schedule CM distribute schedule to: Health care Team RN Pharmacy RN PVP Screenings Vaccines Prior AWV Pharmacy PVP Assess co-pay; Visit Shingles Vaccine Prints med list Checks med refills/90 day supply/allergies Visit Complete SITE: CM/MA/RN Acquire Information (CM) ADL/IADL/Risk Factors Establish list of current providers (Specialists/DME) PMH/FH/SH Advance Directives Mini Cog PACE Eligibility Counsel (RN) Care plan education Document assessments CPOE Order Vaccines If needed (MA) Administer vaccines Give iFOBT Notes:

Where can I find more information about the IPPE and AWV? Medicare Learning Network-IPPE and AWV Information

Medicare AWV: 30-minute webinar  Optimizing Utilization and Implementation of Medicare’s Annual Wellness Visits (AWV) (control click to follow link)

Medicare AWV Questions What are the benefits of providing the wellness visits? What is the difference in the visits? Who can perform the wellness visits? If the visit is done at a FQHC does a provider (MD, DO, PA, NP, and CNM) have to see the patient? If the AWV provider is a NP or PA will the visit count toward ACO assignment?

1. IPPE & Annual Wellness Visits Benefits No cost to patient!! Generates revenue for the health center Supports ACO attribution Opportunity to address gaps in care Opportunity to meet GPRO measures (ex., falls assessment) Could help improve accuracy of HCC coding Potential additional benefits: Keep patients healthy Enhances quality of care Improves patient engagement Promote preventive health Help to build retention

2. The Initial Preventative Physical Exam IPPE (“Welcome to Medicare” Preventive Visit) The patient must receive this service within the first 12 months after the effective date of their Medicare Part B coverage. One-time benefit. Consists of the following: Review the patient’s medical and social history; Review potential risk factors for depression and other mood disorders; Review functional ability and level of safety; Measurement of height, weight, body mass index (BMI), and visual acuity screening. End-of-life planning (upon agreement of the individual); Education, counseling and referral based on the review of previous 5 components; and Education, counseling and referral for other preventive services, including a brief written plan such as a checklist. Who can perform an Initial Preventive Physical Exam? Medicare Part B covers an Initial Preventive Physical Exam if it is furnished by a: Physician (doctor of medicine or osteopathic medicine), or Other qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist) 2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1338.pdf MLN Matters® Number: SE1338 Re-issued

2. 1st AWV and Subsequent AWVs The first AWV includes the following elements: A health risk assessment; Establishment of a current list of provider and suppliers; Review of medical and family history; Measurement of height, weight, BMI, and blood pressure; Review of potential risk factors for depression and other mood disorders; Review of functional ability and level of safety; Detection of any cognitive impairment the patient may have; Establishment of a written screening schedule (such as a checklist); Establishment of a list of risk factors; and Provision of personalized health advice and referral to appropriate health education or other preventive services. Subsequent AWVs include the following elements: Review of updated health risk assessment; Update of list of current providers and suppliers; Update medical and family history; Measurement of weight and blood pressure; Detection of cognitive impairment the patient may have; Update of the written screening schedule (such as a checklist); Update of the list of risk factors; and Provision of personalized health advice and referral to appropriate health education or other preventive services. 2. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1338.pdf MLN Matters® Number: SE1338 Re-issued

3. Who Can Perform the AWV? Who can perform the Annual Wellness Visit? Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by the following: Physician (doctor of medicine or osteopathy) Physician assistant Nurse practitioner Clinical nurse specialist Medical professional (including a health educator, a registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals working under the direct supervision of a physician (doctor of medicine or osteopathy). CMS is not assigning particular tasks or restrictions for specific members of the team. We believe it is better for the supervising physician to assign specific tasks to qualified team members (as long as they are licensed in the State and working within their state’s scope of practice). This approach gives the physician and the team the flexibility needed to address the beneficiary’s particular needs on a particular day. It also empowers the physician to determine whether specific medical professionals who will be working on his or her wellness team are needed on a particular day. The physician is able to determine the coordination of various team members during the AWV. Definitions: Levels of Supervision General Supervision - means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. Direct Supervision - in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean the physician must be present in the room when the procedure is performed. Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure. https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EEL736213?open Medicare area claims processor 3. Frequently Asked Questions from the March 28, 2012 Medicare Preventive Services National Provider Call: The Initial Preventive Physical Exam and the Annual Wellness Visit https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/IPPE-AWV-FAQs.pdf

4. Does a Provider have to see the patient? At a FQHC, Yes Billable Visit- Face-to-face encounter between the patient and a Physician, Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse Midwife (CNM), Visiting Nurse, Clinical Psychologist (CP) or Clinical Social Worker (CSW) during which a FQHC service is rendered. 4. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf Specific Payment Codes for the Federally Qualified Health Center December 2016 Prospective Payment System (FQHC PPS) (Rev. 12-22-16) Sent: Tuesday, July 18, 2017 9:29 AM To: CMS FQHC-PPS <FQHC-PPS@cms.hhs.gov> Subject: Medicare Annual Wellness Visit   If a RN performs the annual wellness visit, is it necessary for the practitioner to see the patient to bill for the service (G0438 or G0439)?

5. Can NPs & PAs perform the AWV for FQHC patients? Yes ACO professional means an individual who is Medicare-enrolled and bills for items and services furnished to Medicare fee-for-service beneficiaries under a Medicare billing number assigned to the TIN of an ACO participant in accordance with applicable Medicare regulations and who is either of the following: (1) A physician legally authorized to practice medicine and surgery by the State in which he or she performs such function or action. (2) A practitioner who is one of the following: (i) A physician assistant (as defined at § 410.74(a)(2) of this chapter). (ii) A nurse practitioner (as defined at § 410.75(b) of this chapter). (iii) A clinical nurse specialist (as defined at § 410.76(b) of this chapter). This is where we have to switch hats between a FQHC and the ACO. In the MSSP regulation ACO professional is defined as … 5. Title 42 - Public Health Chapter IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) Subchapter B - MEDICARE PROGRAM (CONTINUED)Part 425 - MEDICARE SHARED SAVINGS PROGRAMSubpart A - General Provisions Section § 425.20 - Definitions. https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol3/pdf/CFR-2015-title42-vol3-sec425-20.pdf